Perilous medicine in Tigray: a systematic review

Background The war in Tigray, North Ethiopia which started in November 2020, has destroyed decades of the region’s healthcare success. There is some emerging published evidence on attacks on health care in the region, and we synthesized the available evidence on ‘perilous medicine’ in Tigray to understand the data source, subjects and content covered, and what gaps exist. Methods We employed a systematic review and performed a systematic search of MEDLINE, PubMed, CINHAL, Web of Science and Scopus. We included English written documents published from 4 November 2020 to 18–19 October 2022 and updated the search on 23 January 2023. HG and NF independently performed title, abstract and full-text screening. We used Joanna Briggs Institute (JBI) tools to appraise and extract data, and applied content synthesis to analyze. The PROSPERO registration number is CRD42022364964. Results Our systematic review search yielded 8,039 documents, and we finally found 41 documents on conflict and health in Tigray. The areas were: (1) attacks on infrastructure, health or aid workers, patients, ambulances or aid trucks identified in 29 documents—the documents reported targeted attacks on health infrastructure and personnel; (2) interruption of health or social services in 31 documents—the documents reported medical and humanitarian siege; (3) outcomes and direct or indirect impacts in 33 documents—the documents reported increased magnitude of illnesses, and catastrophic humanitarian crises including the use of food, medicine and rape as tools of war; and (4) responses, rebuilding strategies, and recommendations in 21 documents—the documents reported improvisation of services, and calling to seize fire, accountability and allow humanitarian. Conclusions Despite promising studies on conflict and health in Tigray, the documents lack quality of designs and data sources, and depth and diversity of subjects and contents covered; calling further primary studies on a prioritized future research agenda. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-023-00524-x.


Rationale
8 Describe the rationale for the review e context of what is already known √ 4-5

Objectives 8
Provide an explicit statement of the tion(s) the review will address with ence to participants, interventions, parators, and outcomes (PICO) 3 Section/topic # Checklist item Information orted Page ber(s)

Information sources 10
Describe all intended information ces (e.g., electronic databases, contact study authors, trial registers, or other literature sources) with planned dates verage √ 3-4

Search strategy 11
Present draft of search strategy to sed for at least one electronic base, including planned limits, such it could be repeated √ 5

Data management 12a
Describe the mechanism(s) that will sed to manage records and data ughout the review √ 6 Selection process 12b State the process that will be used electing studies (e.g., two pendent reviewers) through each e of the review (i.e., screening, bility, and inclusion in meta-analysis) √ 6 Data collection ess 12c Describe planned method of cting data from reports (e.g., piloting s, done independently, in duplicate), processes for obtaining and confirming from investigators √ 5-6

Data items 13
List and define all variables for h data will be sought (e.g., PICO items, ng sources), any pre-planned data mptions and simplifications List and define all outcomes for h data will be sought, including itization of main and additional omes, with rationale √ 5
• households who were unable to access health services or buy medicines had sharply increased • the war reduced access by 35% points, while households' ability to buy medicine dropped by 8% points • households' ability to access enough soap decreased by 16.6% points, however • the patterns of demand for health services in Tigray did not change appreciably after the start of the war in November 2020 • the war caused no significant change in access to drinking or washing water Abebe et al, 2022 Original article General • Health infrastructure has been severely damaged by the conflict through deliberate destruction, looting and even militant occupation of health facilities • Only 27.5% of hospitals, 17.5% of health centres and none of 712 health posts were fully functional six months into the war.
• A lack of fuel in affected areas has also impeded the operation of Mobile Health Units.
• There were significant attrition and displacement of health workers • Health workers in diasporic networks -such as a large roster maintained by the organisation HPN4Tigray -are eager to provide services directly. But they have been prevented from entering the country for fear of being arrested by the government as activists or terrorists. • SGBV is widespread and used as a weapon of war. Training and support for local leaders, influencers and institutions to support survivors of widespread sexual and gender-based violence (SGBV) is critical. • 300 dialysis sessions (12.5%) entailed using single-use dialyzers for 6 to 8 times. Dialysis frequency was reduced from twice to once weekly or even fortnightly, impairing both quality of treatment and life. • Using expired central venous catheters or exchanging dialyzers after patient deaths was among the desperate measures adopted • Peritoneal dialysis was improvised using locally prepared fluids, saving a few lives. Currently, even intravenous fluid supplies have run out. Advising patients to stop dialysis and live out their remaining days untreated in hospital or at home is the tragic daily predicament of the trained dialysis team. • The authors call upon nephrologists worldwide and relevant international bodies, including the ISN, to appeal to the Ethiopian Government to lift the blockade, re-establish supply chains, and restore health care, including the right to dialysis for the people of Tigray.

Retrospective cohort study patients on haemodialysis
• From the data available between 2013 and 2021, 550 patients received haemodialysis, of whom 181(32.7%) sufferedfromAKIand319(58%) suffered from chronic kidney disease (CKD). More than half of the patients have progressively succumbed to death following interrupted haemodialysis sessions leading to suboptimal haemodialysis. • In 2021, during the war period, there were a total of 81 patients who underwent dialysis services; 69 (82.5%) of whom were newly enrolled patients in the same year. All of these patients have started dialysis on an emergency basis. Nearly half of the patients who are newly enrolled to the haemodialysis centre had only one haemodialysis session per week. • The enrollment of patients in the haemodialysis service has decreased by 37.3% since the war broke out, in contrast to an annual increase by more than 30%. • Mortality of patients under haemodialysis increased from 25.5% (28 deaths from 110 patients) in 2020 to 53% (43 deaths out of 81 patients) in 2021 (p<0.05). Similarly, patientâ€™s lost-to-follow-up increased from 9 to 14% (11/81 vs. 10/110) but was not statistically significant (p=0.49). • Between July 1, 2021, and January 15, 2022, 61 new patients (36 AKI, including 6 patients with pregnancy related complications and 25 patients with CKD who needed emergency dialysis, succumbed owing to lack of haemodialysis supplies). • The authors plead Ethiopian government to must allow the passage of life-saving medicines, essential medical equipment, and consumables for haemodialysis into Tigray. • The authors demand that the relevant bodies including the United Nations, African Union, World Health Organization, Nephrology organizations, and, above all, the Ethiopian federal government (which has the primary responsibility) stand by the health care workers and the patients of Tigray. • As nothing remains at the disposal of the staff caring for patients such as haemodialysis recipients, the international community and organizations with the capacity to help must organize funds to support Ayder Hospital Opinion Health workers • The hemodialysis center in Ayder hospital is currently unable to give appropriate care to kidney failure patients for a lack of access to dialysis supplies and consumables due to the ongoing war and siege. • health facilities can no longer function, and 13% are partly damaged.
• Collapsed health care system and Stoppage of health extension program • Hospitals across Tigray have been vandalised and looted, where 77% of the state • Absence of salary and unable to access hard earned savings due to bank closure • The fact Health workers unable to provide optimal haemolysis care has resulted in vicarious trauma of the health workers treating dialysis patients in the hospital and is manifested as follows: compassion fatigue, irritability, a feeling of bystander guilt; sadness about the patient's victimization, and hopelessness, • financial hardship of patients, Lack of transportation and communication blackouts • loss to follow up of patients • Shortage of dialysis supplies and lack of available basic medications and interruption of haemodialysis service • Deterioration of patient conditions, & Untimely death of patients • Advocacy for a full resumption of access to health to the besieged Tigray, • the provision of mental health service to health workers and special attention to health healthcare workers treating patients with chronic conditions, • the need the United Nations and other members of international community to press to stop the conflict and access the right to access healthcare of the million besieged civilians in Tigray Burki, 2022 Commentary General • Health workers have not been paid for a year.
• Humanitarian workers have been targeted in Tigray including UN and MSF staff • Childhood vaccination rates, which stood at 73% before the war, are now 27%; Coverage with the first dose of the measles vaccine has dropped from 83% to 28%. • An outbreak is a distinct possibility as nearly 900,000 children younger than 5 years have missed the polio vaccine • Half the population in Tigray may now lack access to clean water; and Cholera kits are in short supply.
• The 312 ambulances that served the health-care system have been reduced to 38.
• Most of the 43,140 Tigrayan patients with HIV who were prescribed antiretroviral therapy have been lost to follow-up, as have patients with tuberculosis. • Covid-19 care system collapsed with only less than one in 10 people got the vaccination and no oxygen for critically ill patients.
• Essential medicines are scarce where Tigrayans are in need of vaccines; treatments for HIV, tuberculosis, and malaria; severe acute malnutrition kits; and reproductive health kits. • Scabies is being treated with expired permethrin • 240 patients, including a teenager with HIV and a baby with meningitis, were sent home after the hospital ran out of food.
• The global acute malnutrition rate stood at 28%, far higher than the Emergency where 10% is the threshold.
• Telephone lines were cut in June, 2021 • The federal government in Addis Ababa imposed a punishing blockade.
• Barely any fuel has been permitted to enter, severely curtailing the prospects for travel, especially outside the state capital, Mekelle; and Banking services have been suspended, making it extremely hard to get hold of cash, and access to electricity is patchy or non-existent. • The vast majority of the 7 million people who live in Tigray are struggling to find enough food.
• Almost half a million children are thought to be malnourished • There have been widespread reports of forced displacement, sexual violence, and mass killings, as well as serious violations of international humanitarian law • accusing forces from the Amhara region in western Tigray of ethnic cleansing and crimes against humanity.
• The multiple bureaucratic restrictions on things like visasâ€ by the Ethiopian government to including international aid works and suspension of some NGOs including MSF and the Norwegian Refugee Council not to deliver services in Tigray • Along with ending the effective siege, it is critical that all services, including banking, are restored as itâ€™s impossible deliver healthcare or humanitarian aid on any kind of scale without electricity, fuel, or cash.

Clarfield et al, 2022
Commentary General • Ayder hospital has been forced to cancel basic surgeries • In Ayder Hospital, which only recently could boast of its achievements in providing haemodialysis to those in need, patients with renal failure are dying before the eyes of attending staff due to the lack of basic supplies • The availability of essential medications has, as estimated by the Ayder Hospital, plummeted from almost 80% 1 year ago to less than 20%, and laboratory tests have dropped from 94% to less than 50%. Patients are dying from a simple lack of a reliable oxygen supply. • Due to the blockade of Tigray, spare parts for all medical machinery are not just in short supply--they are non-existent.
• Neurosurgeons are operating without the benefit of imaging, depending on clinical skills only a situation reminiscent of the 19th century.
• a medical catastrophe is unfolding, in the background of war, famine, and a humanitarian tragedy.
• Hospital staff have gone unpaid for most of 2021; and for those who still have some savings, the banks are closed. It is becoming impossible to feed the staff and their children • The authors demand that the relevant bodies, the UN, the African Union, WHO and, above all, the Ethiopian Government stand by the health workers and the patients in Mekele.

Cousins S, 2022
Commentary Women with fistula • more than 80% of health facilities have been destroyed • there had been a drastic increase in the number of obstetric fistula cases, although difficult to know the magnitude. In addition to lack of medicines, and the collapse of transport, a major contributor to the increase of fistula was widespread rape. • The conflict has killed tens of thousands of people and displaced millions, while countless women have suffered rape and sexual assault.
• Women with fistula require sophisticated counselling and specialised surgical care units to avoid a life of social rejection and isolation but none of these services exist at this point and going to continue to be a huge concern Devi S, 2022 Commentary General Commentary General • Barely one in ten health facilities were functioning in Tigray and many were deliberately looted, vandalised, and destroyed in April 2021.
• MSF members, with their MSF-marked vehicle, were stopped by an Ethiopian military convoy • Thousands killed, men forced to rape family members, and destruction of the health system are among the atrocities being uncovered in Tigray by aid agencies after the Ethiopian Government started a military offensive against the ruling faction in the region last November. • US secretary of state (Antony Blinken), used the term â€oeethnic cleansingâ€ for the first time on March 10, 2021, at a foreign affairs committee meeting. He said Ethiopian and Eritrean troops must leave and be replaced by â€oea force that will not abuse the human rights of the people of Tigray or commit acts of ethnic cleansing, which weâ€™ve seen in Western Tigrayâ€. • Almost 2000 people were killed in more than 150 massacres by soldiers, paramilitaries, and insurgents, according to reports compiled by a team from the University of Ghent that crosschecked testimony with family, friends, and media. • MSF staff members also witnessed the extrajudicial killing of at least four men.
• On March 25, 2021, more than 500 rape cases had been reported to clinics in Tigray and the total of such cases was likely to be much higher.
• Women say they have been raped by armed actors; they also told stories of gang rape, rape in front of family members and men being forced to rape their own family members under the threat of violence. But given the fact that most health facilities are not functioning and also the stigma associated with rape, it is projected that actual numbers are much higher. • Patients with chronic diseases such as diabetes, hypertension, and HIV infection, as well as patients in need of psychiatric care, were without lifesaving drugs.

Devi S, 2021
Commentary General • The airstrikes in Mekelle, Capital city of Tigray, threatened the safety of UN staff who were working to help civilians in humanitarian need in Tigray.
• Nearly half of the pregnant and lactating women in Tigray are also now acutely malnourished.
• Medicines and equipment are in short supply in Tigray, where cases of malaria, dysentery, and rabies are Rising.
• Eighteen (18) people, including one child, died because of a lack of haemodialysis catheters at Ayder hospital in Mekelle.
• Ethiopia has suspended for 3 months the work of two aid groups, MÃ©decins Sans FrontiÃ¨res (MSF) and the Norwegian Refugee Council (NRC), who have been delivering service in conflict Zone in Tigray. • Killings, looting, and the destruction of health centres and farms had triggered a surge in humanitarian need in Tigray.
• Nearly 200,000 children had gone without critical vaccinations, and the lack of food had made people more susceptible to deadly diseases.

Devi S, 2021
Commentary General • There is an imminent risk of famine in the Tigray region of northern Ethiopia, with some humanitarian agencies prevented from to providing aid.
• More than 350,000 people are already living with severe food insecurity in Tigray, where 75% of medical facilities remain destroyed or damaged by conflict. • About 5.5 million people of roughly 6 million in the region now face acute food insecurity.
• Declaring a famine would be a politically charged move and famine is not a category in the UN-backed Integrated Food Security Phase Classification (IPC) analysis. The UN estimates that 1.8 million people are in phase 4 or have â€oeemergencyâ€ levels of acute food insecurity and 353,000 people are in phase 5 or â€oecatastropheâ€. • Food and aid are hampered by ongoing conflict, the displacement of around 1.7 million people in northern Ethiopia, road blocks and military restrictions, and disruption to last yearâ€™s crop harvesting and this yearâ€™s planting season, said the IPC. • Mark Lowcock, UN emergency relief coordinator, told Reuters that Eritrean soldiers and local fighters were deliberately blocking supplies to the more than 1 million people in areas outside Government control and food is definitely being used as a weapon of war. • WHO said in its latest bulletin that only 74 of 264 facilities were functional, malaria was expected to rise in the upcoming rainy season, and the lack of routine childhood vaccination meant an increased risk of measles outbreak. • The massive displacement of people meant it was difficult to assess the number of people in need in rural areas.

Devi S, 2020
Commentary General • local hospitals and health facilities were running low on supplies as they treated wounded people, of whom 80% had trauma injuries • The hospital is running dangerously low on sutures, antibiotics, anticoagulants, painkillers, and even gloves • The hospital was lacking body bags and food supplies were also low, affecting those recovering from surgery. MSF reported that there were doing 120 consultations on a daily average in our clinic and at the end of the day there would still be patients not seen • staff at the hospital had to suspend many other medical services to treat wounded patients • After the conflict started, hundreds of foreign aid workers fled and phone and internet connections in Tigray were shut down.
• Tigray region has been under a travel and communications ban by the federal Ethiopian Government.
• Aid trucks have been blocked for weeks and humanitarian access at least to federal government-controlled areas would allow delivery of much-needed aid, including food and medical supplies. Approximately 600,000 people were dependent on food aid in the region even before the conflict. • Food had run out for almost 100,000 refugees from Eritrea who live in three camps in Tigray.

Favara et al, 2022
Cross-sectional study Young people • Allegations of war crimes, mass destruction and looting including of health care facilities have been reported.
• At the time of the second phone call, 2 in 5 young people self-reported at least mild depression and/or mild anxiety, and 16% (95% CI, 9.73-23.06) selfreported both. • Rates of self-reported anxiety were three times higher in November/January than in August/October, and rates of self-reported depression went up by ten percentage points. • For those interviewed after the outbreak, rates of at least mild anxiety were eleven times higher than pre-conflict from 35% (95% CI, 23.44-47.33) to 3% (95% CI, 1.24-7.39). • Rates of at least mild depression more than doubled from 12% (95% CI, 12.31; 4.1-20.51) to 28% (95% CI, 16.52-38.87).
• Males reported greater increases in anxiety, females in depression.

Gebregziabher et al, 2022
Commentary General • The health system in the Tigray region of Ethiopia has been destroyed.
• Only 40 of 268 pre-war ambulances remain • More than 80% of hospitals and health facilities in Tigray have been looted and destroyed • A total of 2000 healthcare workers were reportedly registered in internally displaced people camps in the capital city, Mekelle, as of May 2021.
• After the onset of the war, more than 50% of members of the regional health work force were unable to report to their working institutions.
• The status of the community health extension workers who were in charge of the health extension program became unknown, with their salaries completely cut-off, and their safety not guaranteed. • An estimated at least 20,000 women and young girls have been raped by Eritrean and Ethiopian forces.
• Almost 40% of Tigrayans are suffering from an extreme lack of food, after 15 months of conflict.
• The Government deliberately blocked humanitarian aid that aimed to feed and provide life-saving services to the millions affected.

Gebregziabher et al, 2022
Cross sectional study General • over 67.7% of health centres (153 out of 226) and over 56% of primary hospitals (13 out of 24) in Tigray were non-functional or not communicating.
• Only 25% of all primary hospitals, 10% of all health centres and 0% of all health posts at this point in time were still fully functional • Overall, less than 4% of all healthcare facilities across Tigray were FF as of June 2021 • In central Tigray, two out of six health facilities in Tigray are partially functional and the remainder are non-functional.
• In the East Tigray zone, only 10% of the health centres (4 of 39) were confirmed to be fully functional, and only one of the five primary hospitals was fully functional. Both of the general hospitals in Eastern Tigray remained fully functional. • Mekelle has fared relatively well with 82% of the health centres, one of the two general hospitals, and the zoneâ€™s only referral hospital confirmed remaining fully functional. However, note also that only one of the two primary hospitals in Mekelle was functional. • In the North West Tigray region, only 15% of health centres (6 of 40) were fully functional or partially functional, only one of the two general hospitals remained confirmable as fully functional, and only one of the four primary hospitals remained fully functional. • In the South East Tigray region, less than half of health centres (9 of 22 partially functional and 0 of 22 fully functional) and only one of the three primary hospitals were confirmable as fully functional or partially functional. • In the South East Tigray zone, there were no general hospitals (a situation that existed prior to the onset of this war). Two of the three primary hospitals were confirmed non-functional or not communicating and none of the regionâ€™s 22 health centres was fully functional (only nine are partially functional). In this region, only 4% (1 of 25) of all healthcare facilities remained fully functional. • In the South Tigray region, over one-third of health centres (12 out of 32) were confirmed as fully functional or partially functional, all of general hospitals were confirmed to be fully functional or partially functional, and all primary hospitals were fully functional. In the West Tigray region, less than 5% of health centres (1 out of 21) were fully functional or partially functional, and almost no health facilities were communicating; that is, over 95% of these facilities were under occupation by Eritrean or Amhara forces. • The authors recommend global health associations to list war as a priority health issue.

Gesesew et al, 2022
Commentary Women & girls • 250 war-victim women and girls had been admitted to the clinic due to fistula • Fistula patients could not get treated as they cannot afford cost of transportation and rehabilitation • Risk factors to fistula among women and girls included obstructed labor, malnutrition, gang-rape, & sexually transmitted infections.
• 36/40 hospitals, 208/232 health centers, and 670/741 health posts had been fully destroyed or partially damaged and 274/308 ambulances had been non-functional i.e. burned or looted. • ANC & skilled delivery decreased from 94% to 16% and 81% to 21% in 2019 to 2022 respectively, leading to obstructed labor during birth • There has been an imposed medical siege in the region since June 2021 and the referral system and communication is broken.
• 79% of pregnant & lactating mothers were acutely malnourished in Tigray in October 2021, and 90%+ of the population lack regular access to food • Fistula incidence in Tigray conflict zone is now equally high in women from urban and educated backgrounds as it was in the rural, uneducated, and poor women before the start of the conflict. • the weaponization of sexual violence in Tigray has been documented in many reports, including by Amnesty international.
• Tigray regional health bureau reported that 7.5% of those women and girls who reported that they were raped were diagnosed with an sexually transmitted infections, and of which 5% were HIV-positive.

Gesesew et al, 2021
Analysis General • After the war, virtually the entire MCH service was collapsed and none of the services above were available.
• After the onset of the war, a report by the Health Bureau of the Interim Tigray Administration10 revealed that the HEP has become completely nonfunctional. • Two-thirds of the Woreda Health Offices in the region became non-functional, while the status of the remaining one third (south Tigray, southeast, western and some part of eastern Zones) is unknown as they were under the control of the invading Eritrean and/or Amhara forces. • Out of the assessed 40 hospitals, 21 were non-functional, 12 were partially functional although with severe limitations and the status of the remaining 7 was unknown as they were still under the occupation of the invading Amhara forces and militia. • Out of the assessed 228 health centres in the region, only 40 (17.5%) were functional, while the remaining were either completely non-functional, partially non-functional or their status was unknown due to occupation by the invading Amhara or Eritrean forces. • A total of 238 (90%) of the 269 ambulances which have been serving before the onset of the war were either destroyed or looted.
• The intentional damage of healthcare facilities in Tigray as a potential weapon of war with deliberate destruction and looting has led to displacement of thousands of healthcare workers including death of more than ten workers. • A total of 2000 healthcare workers were reportedly registered in internally displaced people camps in the capital city, Mekelle, as of May 2021.
• After the onset of the war, more than 50% of members of the regional health work force were unable to report to their working institutions.
• The status of the community health extension workers who were in charge of the health extension program became unknown, with their salaries completely cut-off, and their safety not guaranteed. • UNICEF revealed that the level of severe acute malnutrition (SAM) in Tigray in January 2021 was three times of the global WHO emergency threshold, putting 70000 children at risk of death. • MSF found that 26.6% of 309 children screened in mobile clinics at several locations in Northwest Tigray were malnourished and 6% of them were severely acutely malnourished, leading them to conclude this â€˜warrants immediate actionâ€™. • Although there is no reported outbreak to date, given the collapse of the healthcare system, interruption of childhood vaccination, poor sanitation and massive internal displacement, common outbreaks such as cholera, measles, malaria, yellow-fever and COVID-19 are likely to arise or worsen. • There are reports from the WHO which indicate signs of acute watery diarrhoea cases in different towns of Tigray.
• There are also many anecdotal reports of patients with insulin dependent diabetes dying after they run out of their insulin supplies.
• The United States Agency for International Development (USAID) report found that 39% of women and girls reported being raped inside their homes, and 33% of the victims were gang-raped. Moreover, 44% and 33% of the victims were raped by Ethiopian and Eritrean soldiers respectively, 11% did not know who raped them, and 6% by Amhara Militia, and 6% by combinations of Ethiopian and Eritrean soldiers. • Amnesty international revealed that health facilities in Tigray recorded 1288 cases of gender-based violence between February and April 2021. Adigrat Hospital alone recorded 376 rape cases from the beginning of the conflict to the 9 June 2021. • The World Food Programme reported that 5.2 million people (91% of the total population in the region) are food insecure requiring immediate humanitarian assistance, of which 1.2million people women and children will be assisted with nutritionally fortified food by WFP.
• MSFâ€™s mobile clinics were implemented as an alternative response, until suspended by the Federal government; Norwegian Refugee Council (NRC) used to support refugees refugee camps for 33,000 Eritreans in Tigray until the federal government suspended it. • Other humanitarian organisation such as the UNAID and other UN agencies were responding to crisis by refilling medications and providing therapeutic food for malnutrition. • Massive displacement of people and lack of access to insecure areas are just a few consequences of the war that further hamper objective assessment of the situation.

Hadera et al, 2022
Commentary General • Stressed health workers due to constant attack of the drones • No salary and access to transport to go to work for health workers • Lack of enough medications, supplies and emergency services to patients including oxygen and basic test kits.
• 1425 civilians have been the victims of indiscriminate airstrikes (residential areas, hospitals, markets, public transport and other civilian infrastructure • Pregnant and lactating mothers and other women, constitute45% of the total dead and injured.
• Blockade of NGOs who provide health services • spike in death rates • drop in the quality of healthcare services at hospitals • deaths of more than 183 neonates in the past six months and 31% of patients admitted to the ICU.
• Cancelation of 3700 and above surgeries due to a lack of oxygen in 12 months.
• Mortality rate at the emergency department increased from the 0.3% pre-war level to 2.5% at a regional level.
• unsafe blood transfusion as blood banks have run out of testing kits to check for HIV, hepatitis, syphilis

Hailu et al, 2022
Cross sectional study hypertension patients in health facilities • Follow-up/visit of hypertension patients sharply decreased by 85%, 59%, 85%, 100%, and 11% in Eastern, Northwestern, Southeastern, and Southern zones but increased by 59% in Mekelle after the war. • The study did not include western zones due to occupation and ongoing war, and primary hospitals from central and south zones due to destruction of health facilities data. • The study didnâ€™t include private health institutions and referral hospitals in Axum and Mekelle due to unavailability of data. Hiluf  • only 29 of the nearly 230 health centres in Tigray were fully functional as of April 2021.
• Only 1% of health facilities in Tigray had the capacity to provide comprehensive gender-based violence services in April 2021.
• The presence of Ethiopian, Eritrean, and Amhara forces with in communities in Tigray in the first half of 2021 also impacted the work of mobile clinics and community outreach programs. • There were reports of at least five instances in which armed groups threatened, harassed, or detained Tigrayan aid worker s supporting sexual violence survivors or providing reproductive health services for local organizations or international organizations. • Health workers and humanitarian aid providers in Tigray described threats and intimidation linked to their work on sexual violence, and their fear of reprisals from Ethiopian authorities.

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• The health workers also said that the presence of armed forces and groups in communities, including Ethiopian, Eritrean, and Amhara forces, impeded their ability to protect privacy and confidentiality, and to run mobile clinics and community outreach programs. • Aid workers said that without clear, consistent access, they Struggled to adhere to best practices for supporting survivors of gender-based violence, including to provide private, women-friendly spaces. • Mental health care and psychosocial support services, including community-based support and specialized services, are massive gaps in Tigray, as well as other conflict-affected regions • Sexual violence survivors sought the following services: testing, treatment, and termination of pregnancy, testing and treatment for sexually transmitted infections including HIV and Hepatitis B, and physical trauma, including broken bones, bruises, stab wounds, traumatic fistula, and for depression, anxiety, post-traumatic stress, and other mental health conditions. • The presence of soldiers at checkpoints on the roads of Tigray and near or inside health facilities also deterred survivors from seeking health services.
• Rape has been used as a weapon of war, particularly by Ethiopian, Eritrean, and Amhara forces against Tigrayan women and girls.
• Ethiopian Ministry of Health reported 1,324 visits to hospitals in Tigray by survivors of sexual and gender-based violence, including in the cities and towns of Mekelle, Adigrat, Axum, Adwa, Shire, and Maichew; where as Tigray regional Health Bureau reported 2,204 survivors sought services for sexual violence at health facilities from November 2020 to June 2021. The actual number far exceeds due to insecurity, deeply rooted social stigma, and the lack of functioning healthcare facilities. • The Ethiopian and Eritrean armed forces, and regional Amhara militias allied to the Ethiopian army committed numerous grave abuses, including massacres, rape between ages of 6 to 80 years old often accompanied with degrading and ethnic-based slurs, and other sexual violence against women and girls; attacks on refugee camps; and destruction of crops and civilian infrastructure, including healthcare facilities and schools in Tigray. • The armed conflict has also been characterized by the Ethiopian government obstruction of humanitarian assistance in Tigray, which the United Nations has characterized as a de facto blockade. • The Ethiopian government is unlawfully restricting and denying desperately needed food, medical supplies and fuel to the population of Tigray.
• The Ethiopian government has imposed unpredictable bureaucratic obstacles for aid agencies to obtain visas and permissions for goods; engaged in harassment, attacks, and expulsion of humanitarian workers; and shut down basic services in the region, including banking, electricity, and telecommunications. • The Ethiopian government has effectively besieged Tigray since Tigrayan forces retook control of most of the region in late June 2021; this raises concerns that the Ethiopian government is using starvation as a weapon of war, a violation of the Ethiopian criminal code and a war crime under international humanitarian law. • The lack of safety, information, health facilities, medications, trained staff, and transport prevented survivors of sexual violence from seeking or receiving time-sensitive treatments, including during the critical 72-hour window to administer post-exposure prophylaxis to prevent HIV (more than 80% of survivors did not come within 72 hours) and the 120-hour window for emergency contraception to prevent pregnancy. • Healthcare providers in Tigray need mental health support, as these Tigrayan health workers have done so in the context of having their own lives and communities disrupted by conflict, displacement, and loss, and the shutdown of essential services. • Enforce zero tolerance for sexual violence & other violations of international human rights law & international humanitarian law • Allow immediately rapid, full, safe, and unfettered access to humanitarian aid • Strengthen and expand a comprehensive approach to preventing and responding to gender-based violence across Tigray and conflict-affected areas, including at the regional, woreda (district), and village levels. • UN member countries should increase pressure on parties to the conflict to allow rapid and unfettered access to humanitarian aid, and should establish and support an independent international investigation into human rights abuses and war crimes in the Tigray conflict.

Kumar et al, 2022
Commentary General • Between mid-December 2020 and March 2021, MSF teams in Tigray assessed 106 health facilities and found that only 13% functioned normally. Health centres were looted (70%), damaged (30%), occupied by soldiers (20%), and/or rendered completely non-functional (65%). In addition, only 11% of ambulances were available for use, with the majority damaged, looted, or seized by armed groups. • The only oxygen-producing company in Tigray no longer functions owing to lack of spare parts and maintenance, jeopardizing care for COVID-19, which was already hampered by the interruption of vaccinations • The pervasive lack of medication endangers the estimated 180,000 patients with chronic disease in Tigray â€¢ The supply of essential drugs at Ayder hospital dwindled to 17.5%, and an estimated 117 patients have died owing to supply shortages. • In addition to the damage inflicted on Tigrays health infrastructure, many healthcare workers have been killed, displaced, or remain unaccounted for.
• The lack of safety for health workers caused thousands of them to flee, leading to further health worker attrition. The destruction of health institutions and lack of compensation for healthcare workers has prevented providers from returning to work. • Half of all pregnant and breastfeeding women and 13% of Tigrayan children under 5 years old were found to be malnourished; whereby acute malnutrition increases the risk of poor pregnancy outcomes and can cause developmental delays in children. • Amnesty International has reported that Ethiopian and Eritrean soldiers have used gang rape and the intentional spread of HIV as weapons of war.
• Health centers in Tigray reported 1,288 cases of sexual violence between February and April 2021. In the early days of the war, healthcare workers provided care to survivors of sexual violence for termination of pregnancy, testing and treatment for sexually transmitted infections including HIV, and physical trauma. • 21 months of conflict have left thousands dead and millions vulnerable to disease and hunger • The total communications blackout in Tigray has exacerbated difficulties in documenting human rights abuses and prevented the population from accessing health-related information during the COVID-19 pandemic • Approximately 2.1 million people have been reportedly displaced, which has strained resources in a region already confronting food insecurity. In early 2022, 83% of people in Tigray are food-insecure with almost 40% suffering an extreme lack of food. • Comprehensive physical and mental health care is needed to address these humanitarian needs.
• The global health community should provide policy expertise and funding to rebuild the healthcare infrastructure in Tigray.
• Physicians have resorted to recycling single-use devices such as gloves, chest drains, and surgical supplies, which have led to complications such as infections, kidney failure, and amputations. • Local businesses and community members have donated soap, linen, and bedsheets to sustain hospital operations but damaged imaging equipment remains in disrepair because replacement parts cannot pass through the blockaded.
• The global health response in Tigray should prioritize the safety and security of health professionals. International aid organizations can rehabilitate the health workforce by training individuals in the Health Extension Program. • Training the healthcare workforce could be implemented virtually by global institutions, and Multi-Donor Trust Funds from the United Nations aid organizations can also provide health financing and assistance for healthcare workers and staff in Tigray.
• The global health community should collectively engage the Ethiopian government to demand unfettered access for humanitarian supplies to Tigray.
• Humanitarian access could be stepwise: first, access to food, medicines, oxygen tanks, and health professionals; second, the resumption of basic medical services including preventive, diagnostic, and therapeutic procedures; and third, the rebuilding of health centers, and the establishment of new medical facilities, based on current needs. • Global health academics and international aid organizations must advocate on a global stage for full compliance with international law and the lifting of all humanitarian blockades by the Ethiopian government. Makoni M, 2022 Commentary Cancer patients • None of the health facilities in the region, once one of the communities with the best health-care systems in Ethiopia, are currently operating at prewar levels, as a consequence of the unavailability of power, water, and essential devices, which have been looted or destroyed. • The 19-month-long ongoing war in the northern regional state of Tigray has shattered health provision by destroying health facilities, virtually wiping out care for people with cancer in the region. • Patients with terminal disease were being treated with expired medication and paracetamol before an 11-month government blockade and communication blackout in Tigray were eased in early May, 2022, with an airlift by the International Committee of the Red Cross. • Aid agencies are reported to require permission from the Ethiopian Government to deliver cancer drugs.
• The 19-month-long ongoing war in the northern regional state of Tigray has shattered health provision by displacing health workers, virtually wiping out care for people with cancer in the region. • In a humanitarian report in November, 2021, the UN Office for the Coordination of Humanitarian Affairs reported that the cancer treatment programme at the Ayder Referral Hospital in Tigray had closed, leaving some 500 patients without treatment.
• Household food security dropped significantly (p<0.0001) from 59% in 2019 to 15%, and household food insecurity (mild, moderate, or severe) increased from 41% to 85%. • The sharp increase in the prevalence of acute malnutrition and household food insecurity is a direct consequence of the humanitarian aid blockade and the destruction of food sources stemming from the civil war • Some of the defining characteristics of this armed conflict are a total blockade of humanitarian aid, wanton destruction of health facilities, and the displacement of millions of people

Paltiel O et al, 2022
Commentary General • Doctors in Tigray are unpaid and malnourished, doing the unimaginable such as reusing dialyzers, prescribing outdated drugs in inadequate dosages, performing complex surgery without imaging, and all too frequently, sending patients home to die from easily treatable ailments. • In Tigray, child malnutrition is at triple the rate seen in the recent past due to the widespread civil war.
• Malnutrition is occurring even in the middle classes who cannot access their savings.
• Patients, who one year ago could receive up-to-date care with dialysis or chemotherapy, are dying because of a lack of consumables, drugs, and supplies. • UN estimates that more than 90% of the population in the region is in urgent need of humanitarian assistance.
• It is time to support and show solidarity with the dedicated healthcare professionals in Ethiopia who are working around the clock, with extremely limited resources, to provide healthcare to the population. What is missing is food, equipment, and medicine. • World leaders and politicians must step up, and ensure that these resources reach health facilities like Ayder, so that the people of Tigray receive the care they need and deserve, and that their skilled workforce is able to provide, despite their own hunger. •

Phillips et al, 2022
Personal field observation and authors experience General • According to the MSF assessment of 106 medical facilities between mid-December 2020 and early March 2021 in the Tigray region • Health extension program (HEP) could provide a platform for the rapid development approaches: • Populations comprised of forced migrants require mass distribution of uncooked commodity food by HEP staff.
• community-based appraisal operations could be designed to provide continuous information on the epidemiology of nutritional adversity as well as evidence-driven screening and referral. • Community based approach eases evidence-based screening and referral within priority localities could facilitate the targeting of resources on children in greatest need. • The involvement of community mobilization in the screening and referral process could engage local leaders in sustaining screening and referral operations, obviating the need for widespread international team deployment, while enabling external support to be targeted on acute care. • Current operations in Tigray prioritize acute care needs, but if links to a screening and referral operation could be added, this would enhance the lifesaving potential of clinical interventions. • Children who have recovered from acute adversity could be monitored and supported with the provision of ready-to-use therapeutic food, employing MUAC as a community implemented monitoring and referral tool.

Teka et al, 2022
Commentary women with cancer • Generally 70% had been looted, and more than 30% had been damaged; just 13% were functioning normally. During this war, health institutions have been particularly targeted throughout the entire region in Tigray. • With the presence of soldiers at checkpoints on the roads and near health facilities, civilians, especially from outside urban areas, have been prevented from getting medical treatment. • As the result of the damage of health facilities and looting of ambulances, laboring mothers are dying at home. Women with cancer are being sent away to die at home. • For the past 17 months, no chemotherapy drugs have been allowed to enter into Tigray.
Ethiopia planned establishing five radiation centres and all radiation centres are completed except Ayder hospitalâ€™s radiation centre which remains under construction as its process was caught in the war. The radiation therapy equipment bought for the radiation center remains idle in the hospitalâ€™s premises. • All diagnostic procedures and tests are no longer available. Both emergency and elective surgeries are being cancelled due to power outage and lack of basic surgical supplies including surgical gloves, intravenous fluids, and anesthesia drugs. Chemotherapy drugs are no longer available and cancer patients are being sent home to die. • This war has left hundreds of thousands of dead, millions displaced, and pushed millions into starvation and famine • The Tigray conflict has resulted in widespread reports of sexual violence in areas controlled by Ethiopian and Eritrean federal forces, and regional Amhara militias. Reports of rape, gang rape, sexual slavery, torture, beatings and killings of family members, and degrading, ethnic-based slurs have been widespread • The authors ask the global community to show solidarity to end the suffering of women who are fighting a war with in a war. The African Union, the United Nations, international donors, the international community, cancer societies, and physicians worldwide should press all parties to allow unfettered humanitarian aid access and to lift the siege throughout the Tigray region.

Teka et al, 2022
Commentary women with cancer • About 28% of hospitals, 18% of health centers, 11% of ambulances, and none of the 712 health posts remained functional after six months of the war.
• The Ethiopian government imposed a siege on the Tigray region, leading blockade of humanitarian aid blockade, lack of transportation fuel, power outages, communications blackouts, and banking services interruption, and depletion all essential drugs and medical supplies. • running out of screening and diagnostics care and chemotherapeutic drugs; stoppage of surgeries.
• Cervical cancer screening services have fallen by half from the pre-war period • substantial reduction of surgical care for gynecologic malignant disease (from 108 surgeries to 79 during the war and to 45 during the siege.
• lack supplemental oxygen, anesthetic medications, antibiotics, operation theater materials, and fuel to run generators Tesema et al, 2021 Commentary General • An assessment by United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) and others indicated that about 70% of assessed hospitals and health centres in the region were either partially or fully damaged during the war, most ambulances were either looted or destroyed and all the health posts were rendered non-functional; leaving over 2.5million people without access to essential services including the millions of internally displaced people. • A recent UN report revealed that the woreda level health administration structure in Tigray is non-existent or has limited function. For example, there is no system to monitor service delivery in the region. • The most recent reports of the killings of MÃ©decins Sans FrontiÃ¨res staff in the Tigray region vividly show the risks to health workers in the area.
• Evidence also revealed that women and girls were subjected to sexual abuse and gender-based violence in this war.
• The war in the Tigray region of Ethiopia, which started in November 2020, has already caused a considerable number of casualties, massive internal displacement and over 70000 refugees in neighbouring Sudan. • The process of restoring and rebuilding Tigrayâ€™s health system should focus on (a) health system adaptation; (b) protecting, reskilling and empowering the health work-force; and (c) coordinating actors and resources towards creating a sustainable and resilient health system. • Only a few hospitals in Tigray are functional at any capacity, the transportation network has fallen apart, the telecommunications network has been destroyed, and access to safe, timely cesarean delivery has dwindled to almost nothing. • Health workers and humanitarian aid workers were harassed and prevented from distributing supplies.
• Doctors have to go out and beg for food after completing their shifts if they are to feed their families.
• Nurses and surgical technicians are fainting during extended operations from lack of nourishment, but the number of operations is rapidly falling because of lack of anesthetic drugs, surgical sutures, intravenous fluids, and the constantly diminishing institutional capacity. • Rape was used as a weapon of war to terrorize the Tigrayan population.
• Catastrophic complications of obstructed labor have become common place, because the healthcare infrastructure has collapsed. • The world medical community must speak out and condemn against the horrors that are occurring in Tigray, the use of rape as a weapon of war, the use of starvation to achieve political ends, and the deliberate destruction of health care systems and the intentional harm inflicted upon civilians for revenge and partis an political gain. • Thousands of civilians were killed, often in extrajudicial executions. Tens of thousands of Tigrayans fled across the western border, seeking refuge in Sudan, accompanied by the bodies of their not-so-lucky countrymen, which floated down the Tekeze River near Humera. hundreds of thousands of Tigrayans are threatened by starvation as the result of a deliberate, man-made famine promulgated by the invaders. • Millions more are now internal refugees, flooding into Mekelle and facing acute food insecurity, where the genocidal plan is working.

Weldegerima et al, 2022
Commentary Cardiac patients • Nearly 20 months on, displacement, death, and destruction of healthcare facilities have become the defining elements of this armed conflict, putting millions of lives at risk. • The war has led to a near-total collapse of the Tigray regional healthcare system, rendering 70-80% of healthcare facilities in the Tigray region dysfunctional. • Due to the communication blackouts, 16 months into the conflict, the number of Cath Lab procedures and the number of cardiac patients followed in the cardiology unit has dramatically decreased by 50%, leading to the untimely loss of lives with a significant number of preventable home deaths: The number of Cath Lab procedures in 2015 to 2022 is 1, 64, 91, 84, 127, 26, 19, and 7 respectively. • Number of hypertension patients in Ayder hospital reduced from 1800 in 2020 to 900 in February 2022, Rheumatic heart diseases from 1400 to 700, Congenital heart disease from 638 to 319, and ischemic heart disease from 600 to 300, and cardiomyopathies from 400 to 200. • Patients who were receiving at least the basic heart failure drugs are now being sent home by their physicians due to the lack of critical cardioactive drugs and diagnostic tests. • Ayder Hospital has also run out of coagulation profile tests, which are also lacking in Tigray. Computed tomography scan or magneticresonance imaging services are not any longer available. • The steeply deteriorating diagnostic and therapeutic resources are causing a huge psychological impact on patients and practitioners.
• Ayder Hospital staff and their partners are urgently speaking out about the disastrous impact that this war is causing on healthcare delivery.
• The authors request that the national and international cardiology communities provide an urgent response to restore healthcare, prevent further loss of life, and ameliorate the misery of our patients. They urge and call upon all professionals and organizations to be the advocates of our patients and bring support to the patients in Tigray, Northern Ethiopia WFP, 2022 Report general population • While the overall proxy GAM rates for 6-59 months were estimated at 12.7%, of which proxy SAM rates were 3.6%; the proxy GAM rates for children aged 6-23 months was 25.5% and SAM rates of 10% children but, was 7.5% of GAM and 1% of SAM for 24-59 months children. • Out of 279 pregnant or lactating women among the 979 households assessed, the proxy MAM rates were found to be 60.5%, comparable to the average of 53.3% from more than 250,000 screened through September 2021. • only 15% of the pregnant or lactating women classified as moderately malnourished were reportedly taking any supplements (e.g.,SuperCereal sachets) in the 30 days prior to the survey, potentially underscoring the high caseload of unmet needs for PLW continuing to face inadequate dietary intake and lack of access to essential maternal health care services. • Food security in the Tigray Region is worrisome with 83% of households being food insecure (of which 46.4% are moderately food insecure and 37.5% are severely food insecure). The zones recording the highest food insecurity rates are the North western zone (93%), Eastern zone (86%) and the Central zone (84%). • Across the region, 86% of the assessed households identified themselves as host community, 4% identified that they were currently displaced, 4% identified as returnees and a final 5% identified as being of mixed displacement status. • In November, 52 percent of the assessed population reported planting during the recent Harvest season planting season leading up to the data collection period. • Re household hunger scale, 45% of surveyed households were categorised as experiencing little to no hunger, whereas 40% and 15% of surveyed households were categorised as experiencing moderate and severe hunger respectively.
• 76% of households were classified as engaging in high or extreme levels of consumption-based coping strategies • The ability to meet the urgent need for increased food supplies through external sources.
• Critical monitoring of nutrition, mortality, and health outcomes to monitor the severity of the situation over time and to immediately flag any further deteriorations • Monitoring of household outcomes and contributing factors to acute food insecurity in areas of highest concern, to inform operational partners and to prioritise assistance to communities most in need. • Preparations for this face-to-face survey required careful Planning, primarily related to the lack of communication, limited amount of humanitarian fuel, and limited contingency plans in case of emergencies. • The fact that certain areas were removed leads to geographical/accessibility bias Yemane et al, 2022 Commentary women of reproductive age • Health centres, clinics and hospitals throughout Tigray were systematically targeted for destruction, in contravention of the Geneva Conventions and the internationally accepted laws of war. • As a result of the blockade of food and medical supplies to Tigray, even the most rudimentary services at our hospital have started to vanish, as has been previously reported. • We are forced to wash and re-use examination gloves • In Tigray, anti-D immunoglobulin is no longer offered to Rhesus (Rh)-negative women, pharmacy is depleted, and the few drugs that remain are beyond their official shelf lives; and essential drugs such as misoprostol, intravenous fluids, hepatitis B vaccine, antibiotics, chemotherapy agents, diclofenac, surgical sutures and bandages are now unavailable; and laboratory investigations, such as haemoglobin, urinalysis and rudimentary organ function tests, are no longer available. • Global acute malnutrition among children now affects 28% of the paediatric population, and is worsening under conflict conditions. • There are multiple reports of gang rapes that lasted for days, sometimes ending in the deliberate mutilation of the victims.
• Civilians have been massacred, crops destroyed, livestock slaughtered and schools looted • Some 70,000 Tigrayans have f led across the western border to Sudan as refugees.
• Two million Tigrayans have become displaced internally, many fleeing to Mekelle.
• Nearly 90% of the population of Tigray now live in conditions of food insecurity, and some 400,000 people face starvation.
• A de facto humanitarian blockade on the delivery of food and medical supplies to Mekelle was imposed from the beginning, even when the city was under the control of federal troops. • We implore the international community of obstetricians and gynaecologists to raise their voices to demand an end to the blockade of humanitarian aid to Tigray. • The siege must be lifted. The women of Tigray urgently need access to these lifesaving medical supplies.

Gebrearegay et al, 2022
Case study Kidney cases • At least 22 humanitarian aid and health workers have been killed; only 1300 of the more than 20,000 health care workers prior to the war in Tigray are reporting to their duties. • Standardized PD solutions and catheters are not always available in developing countries. This challenge leads to the use of improvised equipment in the management of critically ill children with AKI patients, using a modifed nasogastric tube as a catheter and fortifed Ringers lactate as a PD solution.
• In patients with cardiac impairment, PD is a viable alternative to hemodialysis also because the cardiovascular tolerance of PD is excellent, a challenge leading the clinicians to use of improvised equipment  Case study Kidney patients • Kidney care provision in the embattled Tigray region has been compromised to an unprecedented extent. Patients with end-stage kidney disease can neither be offered optimal dialysis, nor can they be referred for renal replacement therapy elsewhere. • The authors urgently call upon the international nephrology societies and kidney transplant associations to advocate access to immunosuppressive medications for kidney transplant recipients in Tigray, Northern Ethiopia, to avert additional catastrophic events like the reported one.